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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: MEDTRONIC HEART VALVE DIVISION BAND 620BG29 DURAN ANCORE ANNULOPLASTY C; RING, ANNULOPLASTY
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MEDTRONIC HEART VALVE DIVISION BAND 620BG29 DURAN ANCORE ANNULOPLASTY C; RING, ANNULOPLASTY Back to Search Results
Model Number 620BG
Medical Device Problem Code Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code Mitral Regurgitation (1964)
Date of Event 01/15/2018
Type of Reportable Event Serious Injury
Additional Manufacturer Narrative
Conclusion: without the return of the product, no definitive conclusion can be made regarding the clinical observation.If information is provided in the future, a supplemental report will be issued.
 
Event or Problem Description
Medtronic received information that this 29 mm mitral annuloplasty band was implanted and explanted during the same procedure due to moderate regurgitation.No additional adverse patient effects were reported. .
 
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Brand Name
BAND 620BG29 DURAN ANCORE ANNULOPLASTY C
Common Device Name
RING, ANNULOPLASTY
Manufacturer (Section D)
MEDTRONIC HEART VALVE DIVISION
1851 e deere ave
santa ana CA 92705
MDR Report Key7266780
Report Number2025587-2018-00370
Device Sequence Number19196438
Product Code KRH
UDI-Device Identifier00613994759108
UDI-Public00613994759108
Combination Product (Y/N)N
Initial Reporter StateOH
Initial Reporter CountryUS
PMA/510(K) Number
K032810
Number of Events Summarized1
Summary Report (Y/N)N
Device Implanted Year2018
Device Explanted Year2018
Reporter Type Manufacturer
Report Source company representative,health
Initial Reporter Occupation Physician
Type of Report Initial
Report Date (Section B) 02/13/2018
1 Device was Involved in the Event
1 Patient was Involved in the Event
Is this an Adverse Event Report? Yes
Is this a Product Problem Report? No
Operator of Device Health Professional
Device Expiration Date12/06/2021
Device Model Number620BG
Device Catalogue Number620BG29
Was Device Available for Evaluation? No
Type of Report(Section G)Thirty-Day
Initial Date Received by Manufacturer 01/22/2018
Initial Report FDA Received Date02/13/2018
Is This a Single-Use Device that was
Reprocessed and Reused on a Patient? (Y/N)		 No
Patient Sequence Number1
Outcome Attributed to Adverse Event Required Intervention;
Patient Age72 YR
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